Delivering Health Care Access to Rural America Faces Great Challenges
On October 30, Alliance for Health Reform and the Robert Wood Johnson Foundation hosted a briefing called “Rural Health: Laying the Foundation for Health Reform.” Experts provided statistics and stories that pointed to the amplified needs for health care in rural areas, the impact of reform proposals on access and affordability, and the challenges specific to the delivery of primary care to and the use of telemedicine for the rural poor.
The statistics frame the issues and the stories paint the picture. The Rural Policy Research Institute (RUPRI) — represented by Dr. Keith Mueller, RUPRI Health Panel Chair — lays it out that the farther people live from metro areas, the more likely they are to be uninsured, with 23 percent of those in areas with population less than 2,500 being uninsured, compared to 19 percent in urban areas. This is due to fewer rural businesses providing health insurance (64 percent compared to 71 percent in urban areas); more self-employed individuals (40 percent vs. 32 percent) going without insurance; and higher costs of insurance.
Statistics from the National Rural Health Association augment this data, noting that rural adults are more likely to be unemployed. The economic downturn has exacerbated poverty levels in rural areas, with the rural economy losing jobs at a faster rate than the rest of the nation — in February 2009, the rural unemployment rate was 9.8 percent whereas the urban rate was 8.7 percent. Since 2007, 800,000 more rural Americans are uninsured (out of a total 4.6 million jump country-wide).
Dr. Tom Irons of the Brody School of Medicine spoke about how these conditions manifest themselves in the poorest areas of eastern North Carolina, and the work that HealthAssist and the Community Care Plan of Eastern North Carolina have done to provide a collaborative, multi-stakeholder, community-based approach to reaching low-income and uninsured residents with comprehensive medical, dental, and behavioral health services, pharmacy, and educational programs. Let’s be clear: he spoke of rural counties that have only one health care provider — a nurse. He stressed the need for the recruitment and retention of primary care providers. This requires financial incentives that enable recent graduates to deal with college debt as well as to begin and continue their practice in rural communities.
Together with Neal Neuberger, Executive Director of the Institute for e-Health Policy, he laid out the financial challenges to electronic medical record implementation in rural areas. Small rural providers cannot afford to spend their limited technology dollars in trial and error implementations: they need to ensure that what they use meets the standards of the future for telemedicine to succeed. The lack of a health IT workforce in rural communities also deepens the challenge — 30,000 more HIT workers are needed.
So how do the current health reform proposals fare as far as meeting rural health needs? The House and Senate bills would lead to 96 percent coverage in rural areas due primarily to enhanced coverage of Medicaid that would reach people below at least 133 percent of the federal poverty line (the proposals to increase this to at least 150 percent would of course help even more); and to the use of government subsidies to enable mandated access to affordable coverage through Health Insurance Exchanges. Of special importance to rural citizens are the provisions for guaranteed issue, elimination of denials due to pre-existing conditions, forbidding the use of health status as part of premium rating, and requiring assurance of continuous coverage.
Addressing the needs of the poorest of the poor in this country means ensuring that health care reform meets the challenges facing our rural citizens. It will require our sustained advocacy over years to come to continuously improve our health system.